Thursday, August 12, 2010

Episode 72 Cutting

Each year 2 million women worldwide are subjected to the practice offemale circumcision, sometimes called "cutting" (we prefer the term Female Genital Mutilation). This brutal practice is not limited to the Islamic world. As many as 2,000 British school girls may be forced to undergo this horrific procedure over the summer. Apologists for Islam claim FGM is a cultural practice, not a religious requirement while some cultural relativists argue FGM is just a different way of celebrating womanhood and should not be condemned by western outsiders.By addressing these claims, the doubtcasters make their case that Religion may not be the sole source of sexism but it is the greatest obstacle in challenging patriarchy. Also on this episode: the overturning of California proposition 8 may set the stage for legalizing gay marriage nationwide; and a new "Stranger Than Fiction."

To download this or any previous Reasonable Doubts episodes click here. Find the episode you want and right click the "play now" link and select "save target as..."

Thank you for the enjoyable podcast - I have recently discovered you folks and have been going through your episode archive. I find your shows informative, entertaining, and, usually, refreshingly even-handed.

However, I felt that I had to write you about a comment made during your episode on female genital mutilation. Dave made a remark to the effect of, "...well, westerners do the same thing to boys with much more frequency..."

It is intellectually dishonest and somewhat irresponsible to lump FGM and male circumcision together as if they are the same thing. There is a real debate to be had concerning the practice of male circumcision, but conflating the issue with FGM does not contribute to honest discussion.

FGM is done primarily to control the sexuality of the girl and has negative health consequences.

Male circumcision, on the other hand does seem to offer some health Benefits. Whether or not these benefits outweigh the risks and pain of the procedure IS a valid debate. Some of these benefits occur during the 1st year of the child's life. Because of this, it is up to parents to weigh the risks and rewards and determine if the procedure is the right choice for the child.

The following material that I have put in quotes is from THE AMERICAN ACADEMY OF PEDIATRICS policy statement on male circumcision

"Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision. In circumstances in which there are potential benefits and risks, yet the procedure is not essential to the child's current well-being, parents should determine what is in the best interest of the child."

The statement goes on to say:

"Initial retrospective studies suggested that uncircumcised male infants were 10 to 20 times more likely to develop UTI than were circumcised male infants. A review published in 1993 summarized the data from nine studies and reported that uncircumcised male infants had a 12.0-fold increased risk of UTI compared with circumcised infant males. More recent studies using cohort and case-control design also support an association, although reduced in magnitude. These studies have found a three to seven times increased risk of UTI in uncircumcised male infants compared with that in circumcised male infants."

...and later...

"Neonatal circumcision confers some protection from penile cancer; however, circumcision at a later age does not seem to confer the same level of protection. There is at least a threefold increased risk of penile cancer in uncircumcised men; phimosis, a condition that exists only in uncircumcised men, increases this risk further."

Another quote:

"Evidence regarding the relationship of circumcision to STD in general is complex and conflicting. Studies suggest that circumcised males may be less at risk for syphilis than are uncircumcised males. In addition, there is a substantial body of evidence that links noncircumcision in men with risk for HIV infection. Genital ulcers related to STD may increase susceptibility to HIV in both circumcised and uncircumcised men, but uncircumcised status is independently associated with the risk for HIV infection in several studies."

All of these benefits are small, but based on current evidence they seem to be real - and taken together, they are not negligible. If circumcision seriously negatively impacted the individual, these benefits may not be worth the risk. But the procedure does not seem to carry many risks, and the adult child can go on to lead a normal, healthy sex life.

In conclusion - let's continue to debate male circumcision, but let's do so with honest conversation about it's benefits and drawbacks. We shouldn't use the horrors of FGM as an argument against male circumcision - it is disingenuous and it does not address the complexities of the issue.

I think you are reading more into the comments made than were actually there.

Dave's comment came after discussion of female cutting in the west in the 1950's.@15:45: "it's such and archaic ritual its hard to believe its still practised, then again male circumcision is equally archaic and is practised even more prevalently than female circumcision".

Dave was making a specific comparison. Both archaic rituals, both practised today and male cutting is more common. I'm not sure that it is more common but it does seem to be falsely regarded as benign; its not, it is a mutilation that reduces sensitivity.

Dave also implies that male and female cutting are similar in that they are not supported by evidence, but rather by tradition.The quote you supplied "these data are not sufficient to recommend routine neonatal circumcision" suggests that make cutting is performed despite the lack of evidence to justify the procedure.

Dave does not say male and female cutting are the same, but they do share common attributes and thus can be 'lumped together' as if they were similar things, because they are.

The rest of the discussion makes it clear that female genital cutting results in a far greater risk of death, pain and misery than male circumcision (in most cases as they are practised today).

This is eric, the "anonymous" writer you responded to. Thank you for the thoughtful response. I agree with many of your points. My post was actually an edited version of an email I sent to reasonable doubts. I had to loose some of the length (and as a result, nuance) of that original document to fit it in a single post. Perhaps this was a mistake?

On second reading of my post, i can see how it may have come across as more harsh than i intended, and I am sorry for that. In any case, I explained in my email document that while I agree that there are, of course, similarities in the practices, the differences are very significant.

Also, i explained that I have heard other people in the skeptical movement talk about the 2 practices as if they were the same thing. So, I can see how my post appeared to be reading too much into dave's comments - he actually just touched on a theme that I have heard OTHERS in the skeptical community express more explicitly. Still, I thought his comments were a nice jumping-off point for a discussion.

In regards to my post, you wrote:"Dave also implies that male and female cutting are similar in that they are not supported by evidence, but rather by tradition. The quote you supplied "these data are not sufficient to recommend routine neonatal circumcision" suggests that make cutting is performed despite the lack of evidence to justify the procedure."

I specifically included that part of the document because I did not want the other quotes to be taken out of context. They are clearly saying that we don't need to always perform male circ. However, the document then goes on to list many health benefits of male circ. Please don't get me wrong - these benefits are on the small side. But, current evidence does show benefits. Are they big enough to warrant the procedure? I don't know. They seem to advocate for a case by case evaluation.

What I completely agree with you and Dave on is that the procedure should not be done out of tradition. In the interest of full disclosure, we had our infant son circumcised. Was it the right decision? I don't know. But it was not done out of religious or other tradition. We took the health benefits into consideration and decided that less uti & decreased rates of STD and penile cancer were enough of a reason to have the circumcision done. As the science on this progresses, perhaps we will come to learn that it was the wrong choice.

My question to you is - If you had a daughter, would you remove breast tissue from her, or any of her labia?

The "basic" arguments made FOR routine male genital mutilation are the same ones you're making. Arguments with no REAL standing. Sure, you can circumcise your son and say that you're doing your part to reduce any (minute) chance that he'll develop penile cancer later in life. But is that enough to justify the removal of a perfectly functioning part of your newborn son's shaft?

Yes, you can quote the AAP if you'd like, but they are also the same organization that just recently SUPPORTED 'nicking' the clitoris as an acceptable form of FGM in the United States. They are also the organization that states there isn't enough medical evidence for them to support the routine genital mutilation of our boys. The risk of a man getting penile cancer is lower than the rate of a man getting breast cancer (roughly 1 in 200,000 for penile cancer and 1 in 1,000 for breast cancer). Our daughters are more susceptible to getting breast cancer than our boys are to getting penile cancer, but no one is suggesting we remove our daughters' breast tissues at birth to help lower that risk. Why? Because it's asinine. The AAP may state a small improvement in the risk of developing penile cancer later in life if you circumcise your son, but the AMERICAN CANCER SOCIETY does not.

UTI's are present in the absence of regular hygiene. When you leave a boy intact you teach him to clean himself. I don't remove any inner or outer labia in order for my daughters to find it easier to clean themselves, I simply teach them the proper way to wash. The "foreskin" (and I use quotes because I DESPISE that word -- there is no such thing, it's ALL skin of the shaft) doesn't naturally retract until between the ages of 3-4 and 10-11. Until that time all you need to do is a basic "wipe" of the area. Once the skin retracts on its own (and this is something you should NEVER force) then you gently bring the skin back, clean, and let it slide back into place. Smegma will be present at this time because it's the body's natural way to keep the area clean, much like your nose needing to sneeze when dust makes its way in there.

You've quoted a source that needs to appease the public, and the public it needs to appease is the American public. American's are notorious for needing "coddling" wording when it comes to the choices they've made. The breast feeding argument for example; women are always told that breast feeding "reduces" the risks of certain things. That's bull. Formula feeding INCREASES the risks to infants, not the other way around. Why is it said this way? Because American's are sensitive beasts. The AAP will say "Sure, it's not really medically necessary, and the things we've found that it MAY protect against aren't enough for us to endorse the procedure, but we don't want to make you feel bad about doing it."

The rate of circumcision in the United States is at roughly 35% right now. Why? There's a lot of potential reasons. This figure was stumbled upon during a recent study that aimed to find any side effects from circumcision.

Any way you slice it, there is not enough medical evidence to support the procedure. None at all. And you listed one of your reasons as potentially reducing the risk of STI's. Again, that's only in a specific region with specific risk factors. It also only shows to prevent the spread of HIV when it's female to male transmission. And only that was a SLIGHT improvement. It hasn't shown to reduce the risk of male to female, or male to male transmission. What's a much better way, in Western, industrialized society, to help stop the spread of STI's and HIV? Sex education. Condoms work on both circumcised and intact penises.

At any rate, Dave's only comparison of the two were that they are both unnecessary, barbaric procedures that hold next to no medical (and certainly no moral) value. Sure, there are conditions that may develop that may be cause for a circumcision later in life (http://www.cedars-sinai.edu/Patients/Programs-and-Services/Pediatrics/Treatment/Pediatric-Urology/Circumcision.aspx - a list of those conditions), but there are risks in everything. If you REALLY want to be preventative, shouldn't you also be advocating that we perform routine appendectomies on our newborns to reduce their risk of having appendicitis later in life? Or the tonsils? Our boys are far more likely to suffer ill effects from one of those things than from their penis being left intact.

There is no valid argument FOR any routine genital mutilation of ANY kind. Not on our boys and not on our girls. You can try and give the "pros" of male genital mutilation if you'd like, but none of them will hold up. They simply reek of personal guilt and/or self-validation for a procedure you've admittedly forced on your son.

As an aside, here is a letter from the American Cancer Society to the AAP regarding their position on circumcision and penile cancer:

Eric here - thank you for the thoughtful response. I wish I had seen the ACS letter prior to having the procedure to our son - it would have given us more to consider.

To answer a couple of your questions - which were probably rhetorical...No I would not recommend that newborns get appendectomies or have their tonsils removed. Both of these procedures carry more serious risks than does MC. I also would not be in favor of preventative mastectomies for the same reason. (Also - I am of course in favor of sex ed and condom use.)

The way I understood the data, there are certain conditions (early-life UTIs and penile cancer) which happen less frequently only when the MC is done during infancy. This is why we felt we had to make the decision for our son.

As I said before - I am open to the fact that we may not have made the right decision. It was a decision that we did not come to lightly and it was a close call. Whether or not our decision was right, I don't think my statements "reek of personal guilt". From the info we looked at concerning the risks and benefits, and the info we got from out doctors, we made a decision we thought was right for our child at the time. I understand that you think there are no "pros" to MC. From the info I saw, it looked like there were some small, yet real pros. I understand cognitive dissonance, and I know I'm not above it, but if I eventually come to the conclusion that we did make the wrong decision, I suppose I would feel regret, not guilt. As a new parent, I am sure I will make many mistakes - perhaps MC was one of the 1st. If it was a mistake, it was carried out in good conscience.

Just as a hypothetical exercise - even if MC has no health benefits, I still think it is in a completely different league than FGM. FGM often takes away the possibility of the girl to go on to lead a normal sex life. MC typically has no such consequences. The usual consequences are so different that it's hard to consider the practices equally wrong. This is not to say that I would condone the practice of MC if it were shown to have no health/hygiene benefits whatsoever - I would not.

You're full of it, Eric. You either mutilated your child for a bizarre cosmetic reason (ie, i want him to look like daddy!) or a religious reason. Then you try to justify it via some sort of political statements from the AAP instead of real science. The AAP statement of science (which even they admit can not medically justify the mutilation) is essentially the creationist tactic of "teach the controversy. It is a meta-analysis that includes every study regardless of their methodological strength.

Point me to the medical literature in America or Europe that shows any of the correlations mentioned. You can't? Really? It's because all your mentioned studies are non-blinded, extremely biased studies that come out of Africa.

The study was conducted in Africa, comparing tribal groups that performed circumcision to those that didn't. The study ended up finding a slightly smaller rate of AIDS in the tribal grouping that did perform circumcisions. Off this data, the researchers concluded there must be a casual relationship- circumcision must reduce the risk of HIV infection. Issue?The other factors that could be at work were ignored. The vast majority of those tribes that performing circumcision were Muslim (as part of religious superstition), and those not were generally Christian or traditional. These groups live much different lives- from diet, to social norms on sex, to social-economic status (Muslims being the ruling class, Christians generally more poor).Sounds like a bad piece of science to me.

Correct me if I'm wrong, but removing the foreskin, which is simply skin that covers the penis (and may or may not have medical benefits) is quite a far cry from removing the labia and clitoris which serve entirely different functions than the foreskin.

Would it be more appropriate to compare FMG to cutting off the "head" of the penis, and not just some extra skin?